Heidi Splete

More than 1,000 cases of mumps in nine states have been confirmed in the nation's largest mumps outbreak in decades, announced Dr. Julie Gerberding, director of the Centers for Disease Control and Prevention in Atlanta.

The outbreak of mumps cases began in Iowa in December 2005 among college students, whose close living conditions make them susceptible to the virus, Dr. Gerberding said in a press briefing.

By comparison, a yearly average of 265 mumps cases have been reported for the entire country since 2001, while Iowa previously averaged just 5 cases per year since 1996, the CDC reported (MMWR [Dispatch] 2006;55:1–3).

“As clinicians become more aware of what we are looking for, we expect more cases will be diagnosed,” Dr. Gerberding said. “A lot of clinicians have never seen a case of mumps; not everyone presents with swollen glands.”

Most cases occurred in people aged 18–25 years, many of whom had received either one or two doses of the mumps vaccine. Cases are under investigation in Illinois, Indiana, Kansas, Michigan, Minnesota, Missouri, Nebraska, and Wisconsin. Dr. Gerberding declined to name additional states in which suspected but unconfirmed cases are under investigation.

In addition, two individuals have been identified in Iowa who were potentially infectious during nine different commercial flights between March 26 and April 2, to or from cities outside the Midwest, including Tucson, Ariz.; Dallas; and Washington, the CDC said in an official health advisory issued on April 14.

Mumps, an acute viral upper respiratory infection, may present initially with nonspecific symptoms such as myalgia, anorexia, malaise, headache, and fever, and progress to acute onset of unilateral or bilateral tenderness and swelling of parotid or other salivary glands. An estimated 30%–70% of unvaccinated individuals develop typical acute parotitis, but up to 20% of infections are asymptomatic, and nearly 50% are associated with nonspecific symptoms or symptoms that are primarily respiratory, with or without parotitis. Severe complications can include deafness, orchitis, oophoritis, mastitis, meningitis/encephalitis, and spontaneous abortion.

Most people with mumps are ill for about a week, and they can be contagious from 3 days before symptoms appear until about 9 days after the appearance of symptoms, according to the CDC.

“It's very important for health care workers to have a second dose of the MMR vaccine,” Dr. Gerberding emphasized.

Health care providers in affected areas are advised to offer the MMR vaccine to individuals without evidence of immunity, including all unvaccinated individuals born after 1957. In addition, a second dose is recommended for school-age children, college students, and other high-risk groups.

Most children have received both doses, but vaccine coverage rates will vary with location and population, Dr. Gerberding said.

The supply of MMR vaccine is adequate to cope with the outbreak, Dr. Gerberding said. The CDC will assist states with vaccine supplies as needed, and Merck has donated 25,000 doses to the CDC's stockpile.

“Vaccine coverage matters,” Dr. Gerberding said. “We have no information to suggest that there is any problem with the vaccine.” The problem, she explained, is a lack of complete coverage with a vaccine that is not 100% effective. About 10% of people who receive both doses simply fail to respond and remain susceptible to mumps.

Individuals suspected to have mumps should be tested and any positive cases reported immediately to local public health officials. Such individuals should be isolated for 9 days after symptom onset, the CDC advised.

Physicians should familiarize themselves with the clinical presentations of mumps, said Dr. Mary Anne Jackson, chief of infectious disease at Children's Mercy Hospital, Kansas City, Mo. Some patients complain of pain at the corner of the jaw, or of an earache that can be confused with otitis. Ovarian inflammation, which may occur in up to 5% of infected post-pubertal females, may be confused with appendicitis.

At the time of the press briefing, no deaths related to the mumps outbreak had been reported, Dr. Gerberding said.

More than 1,000 cases of mumps in nine states have been confirmed in the nation's largest mumps outbreak in decades, announced Dr. Julie Gerberding, director of the Centers for Disease Control and Prevention in Atlanta.

The outbreak of mumps cases began in Iowa in December 2005 among college students, whose close living conditions make them susceptible to the virus, Dr. Gerberding said in a press briefing.

By comparison, a yearly average of 265 mumps cases have been reported for the entire country since 2001, while Iowa previously averaged just 5 cases per year since 1996, the CDC reported (MMWR [Dispatch] 2006;55:1–3).

“As clinicians become more aware of what we are looking for, we expect more cases will be diagnosed,” Dr. Gerberding said. “A lot of clinicians have never seen a case of mumps; not everyone presents with swollen glands.”

Most cases occurred in people aged 18–25 years, many of whom had received either one or two doses of the mumps vaccine. Cases are under investigation in Illinois, Indiana, Kansas, Michigan, Minnesota, Missouri, Nebraska, and Wisconsin. Dr. Gerberding declined to name additional states in which suspected but unconfirmed cases are under investigation.

In addition, two individuals have been identified in Iowa who were potentially infectious during nine different commercial flights between March 26 and April 2, to or from cities outside the Midwest, including Tucson, Ariz.; Dallas; and Washington, the CDC said in an official health advisory issued on April 14.

Mumps, an acute viral upper respiratory infection, may present initially with nonspecific symptoms such as myalgia, anorexia, malaise, headache, and fever, and progress to acute onset of unilateral or bilateral tenderness and swelling of parotid or other salivary glands. An estimated 30%–70% of unvaccinated individuals develop typical acute parotitis, but up to 20% of infections are asymptomatic, and nearly 50% are associated with nonspecific symptoms or symptoms that are primarily respiratory, with or without parotitis. Severe complications can include deafness, orchitis, oophoritis, mastitis, meningitis/encephalitis, and spontaneous abortion.

Most people with mumps are ill for about a week, and they can be contagious from 3 days before symptoms appear until about 9 days after the appearance of symptoms, according to the CDC.

“It's very important for health care workers to have a second dose of the MMR vaccine,” Dr. Gerberding emphasized.

Health care providers in affected areas are advised to offer the MMR vaccine to individuals without evidence of immunity, including all unvaccinated individuals born after 1957. In addition, a second dose is recommended for school-age children, college students, and other high-risk groups.

Most children have received both doses, but vaccine coverage rates will vary with location and population, Dr. Gerberding said.

The supply of MMR vaccine is adequate to cope with the outbreak, Dr. Gerberding said. The CDC will assist states with vaccine supplies as needed, and Merck has donated 25,000 doses to the CDC's stockpile.

“Vaccine coverage matters,” Dr. Gerberding said. “We have no information to suggest that there is any problem with the vaccine.” The problem, she explained, is a lack of complete coverage with a vaccine that is not 100% effective. About 10% of people who receive both doses simply fail to respond and remain susceptible to mumps.

Individuals suspected to have mumps should be tested and any positive cases reported immediately to local public health officials. Such individuals should be isolated for 9 days after symptom onset, the CDC advised.

Physicians should familiarize themselves with the clinical presentations of mumps, said Dr. Mary Anne Jackson, chief of infectious disease at Children's Mercy Hospital, Kansas City, Mo. Some patients complain of pain at the corner of the jaw, or of an earache that can be confused with otitis. Ovarian inflammation, which may occur in up to 5% of infected post-pubertal females, may be confused with appendicitis.

At the time of the press briefing, no deaths related to the mumps outbreak had been reported, Dr. Gerberding said.

More than 1,000 cases of mumps in nine states have been confirmed in the nation's largest mumps outbreak in decades, announced Dr. Julie Gerberding, director of the Centers for Disease Control and Prevention in Atlanta.

The outbreak of mumps cases began in Iowa in December 2005 among college students, whose close living conditions make them susceptible to the virus, Dr. Gerberding said in a press briefing.

By comparison, a yearly average of 265 mumps cases have been reported for the entire country since 2001, while Iowa previously averaged just 5 cases per year since 1996, the CDC reported (MMWR [Dispatch] 2006;55:1–3).

“As clinicians become more aware of what we are looking for, we expect more cases will be diagnosed,” Dr. Gerberding said. “A lot of clinicians have never seen a case of mumps; not everyone presents with swollen glands.”

Most cases occurred in people aged 18–25 years, many of whom had received either one or two doses of the mumps vaccine. Cases are under investigation in Illinois, Indiana, Kansas, Michigan, Minnesota, Missouri, Nebraska, and Wisconsin. Dr. Gerberding declined to name additional states in which suspected but unconfirmed cases are under investigation.

In addition, two individuals have been identified in Iowa who were potentially infectious during nine different commercial flights between March 26 and April 2, to or from cities outside the Midwest, including Tucson, Ariz.; Dallas; and Washington, the CDC said in an official health advisory issued on April 14.

Mumps, an acute viral upper respiratory infection, may present initially with nonspecific symptoms such as myalgia, anorexia, malaise, headache, and fever, and progress to acute onset of unilateral or bilateral tenderness and swelling of parotid or other salivary glands. An estimated 30%–70% of unvaccinated individuals develop typical acute parotitis, but up to 20% of infections are asymptomatic, and nearly 50% are associated with nonspecific symptoms or symptoms that are primarily respiratory, with or without parotitis. Severe complications can include deafness, orchitis, oophoritis, mastitis, meningitis/encephalitis, and spontaneous abortion.

Most people with mumps are ill for about a week, and they can be contagious from 3 days before symptoms appear until about 9 days after the appearance of symptoms, according to the CDC.

“It's very important for health care workers to have a second dose of the MMR vaccine,” Dr. Gerberding emphasized.

Health care providers in affected areas are advised to offer the MMR vaccine to individuals without evidence of immunity, including all unvaccinated individuals born after 1957. In addition, a second dose is recommended for school-age children, college students, and other high-risk groups.

Most children have received both doses, but vaccine coverage rates will vary with location and population, Dr. Gerberding said.

The supply of MMR vaccine is adequate to cope with the outbreak, Dr. Gerberding said. The CDC will assist states with vaccine supplies as needed, and Merck has donated 25,000 doses to the CDC's stockpile.

“Vaccine coverage matters,” Dr. Gerberding said. “We have no information to suggest that there is any problem with the vaccine.” The problem, she explained, is a lack of complete coverage with a vaccine that is not 100% effective. About 10% of people who receive both doses simply fail to respond and remain susceptible to mumps.

Individuals suspected to have mumps should be tested and any positive cases reported immediately to local public health officials. Such individuals should be isolated for 9 days after symptom onset, the CDC advised.

Physicians should familiarize themselves with the clinical presentations of mumps, said Dr. Mary Anne Jackson, chief of infectious disease at Children's Mercy Hospital, Kansas City, Mo. Some patients complain of pain at the corner of the jaw, or of an earache that can be confused with otitis. Ovarian inflammation, which may occur in up to 5% of infected post-pubertal females, may be confused with appendicitis.

At the time of the press briefing, no deaths related to the mumps outbreak had been reported, Dr. Gerberding said.

ATLANTA — About 80% of Salmonella cases in the United States in 2004 and 2005 were domestically acquired isolated incidents, Dina Hoefer reported in a poster presented at the International Conference on Emerging Infectious Diseases.

By contrast, about 12% of infected patients with known travel status had traveled internationally, and almost 8% of cases were associated with a recognized outbreak, based on data from the Foodborne Diseases Active Surveillance Network (FoodNet).

FoodNet is an ongoing program, supported by the Centers for Disease Control and Prevention, the U.S. Department of Agriculture, and the Food and Drug Administration, that seeks to link foodborne illnesses to specific foods and settings based on information collected from 10 sites throughout the United States.

Ms. Hoefer, of the New York State Department of Health in Albany, and her colleagues reviewed FoodNet surveillance data for 12,159 cases of Salmonella infection from 2004 and 2005. Of the 7,500 patients whose travel status and outbreak associations were known, 878 had traveled internationally within 7 days prior to the onset of illness, and 583 were known to be part of a documented Salmonella outbreak.

Overall, the domestically acquired cases were significantly more likely to require hospitalization, compared with travel-related cases (relative risk 1.5) or cases associated with outbreaks (relative risk 1.4).

ATLANTA — About 80% of Salmonella cases in the United States in 2004 and 2005 were domestically acquired isolated incidents, Dina Hoefer reported in a poster presented at the International Conference on Emerging Infectious Diseases.

By contrast, about 12% of infected patients with known travel status had traveled internationally, and almost 8% of cases were associated with a recognized outbreak, based on data from the Foodborne Diseases Active Surveillance Network (FoodNet).

FoodNet is an ongoing program, supported by the Centers for Disease Control and Prevention, the U.S. Department of Agriculture, and the Food and Drug Administration, that seeks to link foodborne illnesses to specific foods and settings based on information collected from 10 sites throughout the United States.

Ms. Hoefer, of the New York State Department of Health in Albany, and her colleagues reviewed FoodNet surveillance data for 12,159 cases of Salmonella infection from 2004 and 2005. Of the 7,500 patients whose travel status and outbreak associations were known, 878 had traveled internationally within 7 days prior to the onset of illness, and 583 were known to be part of a documented Salmonella outbreak.

Overall, the domestically acquired cases were significantly more likely to require hospitalization, compared with travel-related cases (relative risk 1.5) or cases associated with outbreaks (relative risk 1.4).

ATLANTA — About 80% of Salmonella cases in the United States in 2004 and 2005 were domestically acquired isolated incidents, Dina Hoefer reported in a poster presented at the International Conference on Emerging Infectious Diseases.

By contrast, about 12% of infected patients with known travel status had traveled internationally, and almost 8% of cases were associated with a recognized outbreak, based on data from the Foodborne Diseases Active Surveillance Network (FoodNet).

FoodNet is an ongoing program, supported by the Centers for Disease Control and Prevention, the U.S. Department of Agriculture, and the Food and Drug Administration, that seeks to link foodborne illnesses to specific foods and settings based on information collected from 10 sites throughout the United States.

Ms. Hoefer, of the New York State Department of Health in Albany, and her colleagues reviewed FoodNet surveillance data for 12,159 cases of Salmonella infection from 2004 and 2005. Of the 7,500 patients whose travel status and outbreak associations were known, 878 had traveled internationally within 7 days prior to the onset of illness, and 583 were known to be part of a documented Salmonella outbreak.

Overall, the domestically acquired cases were significantly more likely to require hospitalization, compared with travel-related cases (relative risk 1.5) or cases associated with outbreaks (relative risk 1.4).

ATLANTA — As summer approaches, it may be wise to be wary of berries. Five norovirus outbreaks affecting several hundred people in Denmark in 2005 were traced to a single batch of contaminated frozen raspberries, Dr. Gerhard Falkenhorst reported at the International Conference on Emerging Infectious Diseases.

The first cases of illness in each outbreak appeared within 24 hours after the patients ate a raspberry dessert, and norovirus was detected in stool samples from all but one outbreak, said Dr. Falkenhorst, of the Statens Serum Institut, Copenhagen.

The outbreaks occurred between May and September 2005, and all of them involved mass catering settings—one hospital, one meals-on-wheels service, one restaurant, and two nursing homes. All of the outbreaks involved desserts made with frozen raspberries.

The first outbreak occurred in a hospital, and patients and staff members reported acute gastroenteritis. Nearly 450 cases occurred in this outbreak. Several cases occurred simultaneously, suggesting a foodborne cause, and norovirus was discovered in food tracings that implicated a dessert made with raspberries that were part of a single, large shipment from Poland. Although the supplier began a voluntary recall of the shipment, the affected raspberries had already been sent to other clients and were linked to several other outbreaks.

The second outbreak affected about 70 residents and staff members at a nursing home the day after a raspberry dessert had been served, and the third outbreak struck several hundred clients of a meals-on-wheels service, which reported diarrhea and vomiting in its clients within 2 days of receiving raspberry desserts. The attack rate was especially high in patients aged 85 years and older, Dr. Falkenhorst noted.

A case-control study confirmed that all the desserts associated with the outbreaks were prepared with crushed frozen raspberries from the same batch imported from Poland. The same norovirus genogroup (II.7) was identified in 24 of 54 stool samples from one outbreak and 9 of 11 stool samples from the second outbreak. In addition, norovirus genogroup II.4 was found in 15 of 15 samples from a third outbreak and genogroup II.b was found in 4 of 8 samples from another outbreak.

This series of outbreaks was the first time several different norovirus strains were detected in stool samples involving the same raspberry vehicle, he noted. He suggested contamination at several points during the processing of the raspberries could have contributed to the presence of multiple norovirus strains.

ATLANTA — As summer approaches, it may be wise to be wary of berries. Five norovirus outbreaks affecting several hundred people in Denmark in 2005 were traced to a single batch of contaminated frozen raspberries, Dr. Gerhard Falkenhorst reported at the International Conference on Emerging Infectious Diseases.

The first cases of illness in each outbreak appeared within 24 hours after the patients ate a raspberry dessert, and norovirus was detected in stool samples from all but one outbreak, said Dr. Falkenhorst, of the Statens Serum Institut, Copenhagen.

The outbreaks occurred between May and September 2005, and all of them involved mass catering settings—one hospital, one meals-on-wheels service, one restaurant, and two nursing homes. All of the outbreaks involved desserts made with frozen raspberries.

The first outbreak occurred in a hospital, and patients and staff members reported acute gastroenteritis. Nearly 450 cases occurred in this outbreak. Several cases occurred simultaneously, suggesting a foodborne cause, and norovirus was discovered in food tracings that implicated a dessert made with raspberries that were part of a single, large shipment from Poland. Although the supplier began a voluntary recall of the shipment, the affected raspberries had already been sent to other clients and were linked to several other outbreaks.

The second outbreak affected about 70 residents and staff members at a nursing home the day after a raspberry dessert had been served, and the third outbreak struck several hundred clients of a meals-on-wheels service, which reported diarrhea and vomiting in its clients within 2 days of receiving raspberry desserts. The attack rate was especially high in patients aged 85 years and older, Dr. Falkenhorst noted.

A case-control study confirmed that all the desserts associated with the outbreaks were prepared with crushed frozen raspberries from the same batch imported from Poland. The same norovirus genogroup (II.7) was identified in 24 of 54 stool samples from one outbreak and 9 of 11 stool samples from the second outbreak. In addition, norovirus genogroup II.4 was found in 15 of 15 samples from a third outbreak and genogroup II.b was found in 4 of 8 samples from another outbreak.

This series of outbreaks was the first time several different norovirus strains were detected in stool samples involving the same raspberry vehicle, he noted. He suggested contamination at several points during the processing of the raspberries could have contributed to the presence of multiple norovirus strains.

ATLANTA — As summer approaches, it may be wise to be wary of berries. Five norovirus outbreaks affecting several hundred people in Denmark in 2005 were traced to a single batch of contaminated frozen raspberries, Dr. Gerhard Falkenhorst reported at the International Conference on Emerging Infectious Diseases.

The first cases of illness in each outbreak appeared within 24 hours after the patients ate a raspberry dessert, and norovirus was detected in stool samples from all but one outbreak, said Dr. Falkenhorst, of the Statens Serum Institut, Copenhagen.

The outbreaks occurred between May and September 2005, and all of them involved mass catering settings—one hospital, one meals-on-wheels service, one restaurant, and two nursing homes. All of the outbreaks involved desserts made with frozen raspberries.

The first outbreak occurred in a hospital, and patients and staff members reported acute gastroenteritis. Nearly 450 cases occurred in this outbreak. Several cases occurred simultaneously, suggesting a foodborne cause, and norovirus was discovered in food tracings that implicated a dessert made with raspberries that were part of a single, large shipment from Poland. Although the supplier began a voluntary recall of the shipment, the affected raspberries had already been sent to other clients and were linked to several other outbreaks.

The second outbreak affected about 70 residents and staff members at a nursing home the day after a raspberry dessert had been served, and the third outbreak struck several hundred clients of a meals-on-wheels service, which reported diarrhea and vomiting in its clients within 2 days of receiving raspberry desserts. The attack rate was especially high in patients aged 85 years and older, Dr. Falkenhorst noted.

A case-control study confirmed that all the desserts associated with the outbreaks were prepared with crushed frozen raspberries from the same batch imported from Poland. The same norovirus genogroup (II.7) was identified in 24 of 54 stool samples from one outbreak and 9 of 11 stool samples from the second outbreak. In addition, norovirus genogroup II.4 was found in 15 of 15 samples from a third outbreak and genogroup II.b was found in 4 of 8 samples from another outbreak.

This series of outbreaks was the first time several different norovirus strains were detected in stool samples involving the same raspberry vehicle, he noted. He suggested contamination at several points during the processing of the raspberries could have contributed to the presence of multiple norovirus strains.

ATLANTA — Just when you thought that prepackaged deli meat was safe, a gastroenteritis outbreak among river rafters in Colorado was traced to norovirus in prepackaged chicken and beef, Dr. Ezra J. Barzilay said at the International Conference on Emerging Infectious Diseases.

On September 18, 2005, the National Park Service contacted the Centers for Disease Control and Prevention to report an outbreak of 136 cases of gastroenteritis in 3 weeks among rafters who participated in group trips on the Colorado River, said Dr. Barzilay, an epidemiologist at the CDC.

“Norovirus accounts for about 50% of all foodborne outbreaks in the US,” he noted.

The cases occurred among participants in 12 of 90 trips conducted by 16 rafting companies during the 3-week period.

Most rafting trips last from 2–14 days. Perishable food is carried in cold storage containers on each raft. Typical rafts carry six to eight people as well as a guide, and each raft carries a portable excrement storage container known as an “ammo can.”

Dr. Barzilay and his colleagues interviewed rafters who went on trips on which people became ill. An “ill rafter” was defined as a rafter or guide who suffered vomiting or diarrhea while on a rafting trip between August 19 and September 12, 2005. An “ill trip” was defined as a trip with three or more ill rafters. “Cases” were individuals who became ill within the first 48 hours of a trip, and controls were individuals who were not ill within 72 hours of the start of the trip or who were never ill.

“The mean incubation for norovirus is about 33 hours, so we looked at possible exposure to the virus on the launch date of any given trip,” Dr. Barzilay said. A review of 57 cases and 96 controls showed that cases were 7.3 times more likely than controls to have consumed deli meat. Deli meat was served for either lunch or dinner on the first day of each of the trips on which people became ill.

Ultimately, three of five composite stool samples from the “ammo cans” on trips sponsored by two rafting companies tested positive for norovirus, as did two of four individual stool samples from ill rafters; all positive norovirus samples were of the same genetic sequence.

The rafters came from different geographic locations, and the ill trips did not use the same raft guides or equipment. All ill trips were launched by 5 of 16 rafting companies, and these 5 companies shared three food suppliers. Both chicken and beef from a single plant that supplied meats to five rafting companies tested positive for norovirus, despite the fact that the meat was vacuum-packed and frozen at −10° F for 7–28 days before shipping.

While visiting the plant where the contamination was thought to originate, the CDC investigators learned that a food handler had become ill around the time that the deli meat for the rafting companies was processed. “He was most likely still shedding virus when he returned to work, and he cross-contaminated that meat,” Dr. Barzilay said.

The food handler became ill on August 13, but he was working at the plant on August 15 and 16; the deli meat was shipped on August 18, and the first case of illness was reported on August 19. “This is the first report of food product contaminated at the point of processing in a government-inspected plant,” Dr. Barzilay noted.

Physicians who see patients with foodborne illnesses should consider that food involved in disease outbreaks may have been contaminated at the point of processing, rather than the point of service.

“Although we think of norovirus contamination occurring at point of service, we suspect that contamination can also occur at point of processing for prepackaged and ready-to-eat foods,” Dr. Barzilay said. Norovirus is highly resilient and can survive on surfaces for extended periods of time, he noted, adding that food handlers who become ill should stay home from work for 24 hours after their symptoms resolve.

ATLANTA — Just when you thought that prepackaged deli meat was safe, a gastroenteritis outbreak among river rafters in Colorado was traced to norovirus in prepackaged chicken and beef, Dr. Ezra J. Barzilay said at the International Conference on Emerging Infectious Diseases.

On September 18, 2005, the National Park Service contacted the Centers for Disease Control and Prevention to report an outbreak of 136 cases of gastroenteritis in 3 weeks among rafters who participated in group trips on the Colorado River, said Dr. Barzilay, an epidemiologist at the CDC.

“Norovirus accounts for about 50% of all foodborne outbreaks in the US,” he noted.

The cases occurred among participants in 12 of 90 trips conducted by 16 rafting companies during the 3-week period.

Most rafting trips last from 2–14 days. Perishable food is carried in cold storage containers on each raft. Typical rafts carry six to eight people as well as a guide, and each raft carries a portable excrement storage container known as an “ammo can.”

Dr. Barzilay and his colleagues interviewed rafters who went on trips on which people became ill. An “ill rafter” was defined as a rafter or guide who suffered vomiting or diarrhea while on a rafting trip between August 19 and September 12, 2005. An “ill trip” was defined as a trip with three or more ill rafters. “Cases” were individuals who became ill within the first 48 hours of a trip, and controls were individuals who were not ill within 72 hours of the start of the trip or who were never ill.

“The mean incubation for norovirus is about 33 hours, so we looked at possible exposure to the virus on the launch date of any given trip,” Dr. Barzilay said. A review of 57 cases and 96 controls showed that cases were 7.3 times more likely than controls to have consumed deli meat. Deli meat was served for either lunch or dinner on the first day of each of the trips on which people became ill.

Ultimately, three of five composite stool samples from the “ammo cans” on trips sponsored by two rafting companies tested positive for norovirus, as did two of four individual stool samples from ill rafters; all positive norovirus samples were of the same genetic sequence.

The rafters came from different geographic locations, and the ill trips did not use the same raft guides or equipment. All ill trips were launched by 5 of 16 rafting companies, and these 5 companies shared three food suppliers. Both chicken and beef from a single plant that supplied meats to five rafting companies tested positive for norovirus, despite the fact that the meat was vacuum-packed and frozen at −10° F for 7–28 days before shipping.

While visiting the plant where the contamination was thought to originate, the CDC investigators learned that a food handler had become ill around the time that the deli meat for the rafting companies was processed. “He was most likely still shedding virus when he returned to work, and he cross-contaminated that meat,” Dr. Barzilay said.

The food handler became ill on August 13, but he was working at the plant on August 15 and 16; the deli meat was shipped on August 18, and the first case of illness was reported on August 19. “This is the first report of food product contaminated at the point of processing in a government-inspected plant,” Dr. Barzilay noted.

Physicians who see patients with foodborne illnesses should consider that food involved in disease outbreaks may have been contaminated at the point of processing, rather than the point of service.

“Although we think of norovirus contamination occurring at point of service, we suspect that contamination can also occur at point of processing for prepackaged and ready-to-eat foods,” Dr. Barzilay said. Norovirus is highly resilient and can survive on surfaces for extended periods of time, he noted, adding that food handlers who become ill should stay home from work for 24 hours after their symptoms resolve.

ATLANTA — Just when you thought that prepackaged deli meat was safe, a gastroenteritis outbreak among river rafters in Colorado was traced to norovirus in prepackaged chicken and beef, Dr. Ezra J. Barzilay said at the International Conference on Emerging Infectious Diseases.

On September 18, 2005, the National Park Service contacted the Centers for Disease Control and Prevention to report an outbreak of 136 cases of gastroenteritis in 3 weeks among rafters who participated in group trips on the Colorado River, said Dr. Barzilay, an epidemiologist at the CDC.

“Norovirus accounts for about 50% of all foodborne outbreaks in the US,” he noted.

The cases occurred among participants in 12 of 90 trips conducted by 16 rafting companies during the 3-week period.

Most rafting trips last from 2–14 days. Perishable food is carried in cold storage containers on each raft. Typical rafts carry six to eight people as well as a guide, and each raft carries a portable excrement storage container known as an “ammo can.”

Dr. Barzilay and his colleagues interviewed rafters who went on trips on which people became ill. An “ill rafter” was defined as a rafter or guide who suffered vomiting or diarrhea while on a rafting trip between August 19 and September 12, 2005. An “ill trip” was defined as a trip with three or more ill rafters. “Cases” were individuals who became ill within the first 48 hours of a trip, and controls were individuals who were not ill within 72 hours of the start of the trip or who were never ill.

“The mean incubation for norovirus is about 33 hours, so we looked at possible exposure to the virus on the launch date of any given trip,” Dr. Barzilay said. A review of 57 cases and 96 controls showed that cases were 7.3 times more likely than controls to have consumed deli meat. Deli meat was served for either lunch or dinner on the first day of each of the trips on which people became ill.

Ultimately, three of five composite stool samples from the “ammo cans” on trips sponsored by two rafting companies tested positive for norovirus, as did two of four individual stool samples from ill rafters; all positive norovirus samples were of the same genetic sequence.

The rafters came from different geographic locations, and the ill trips did not use the same raft guides or equipment. All ill trips were launched by 5 of 16 rafting companies, and these 5 companies shared three food suppliers. Both chicken and beef from a single plant that supplied meats to five rafting companies tested positive for norovirus, despite the fact that the meat was vacuum-packed and frozen at −10° F for 7–28 days before shipping.

While visiting the plant where the contamination was thought to originate, the CDC investigators learned that a food handler had become ill around the time that the deli meat for the rafting companies was processed. “He was most likely still shedding virus when he returned to work, and he cross-contaminated that meat,” Dr. Barzilay said.

The food handler became ill on August 13, but he was working at the plant on August 15 and 16; the deli meat was shipped on August 18, and the first case of illness was reported on August 19. “This is the first report of food product contaminated at the point of processing in a government-inspected plant,” Dr. Barzilay noted.

Physicians who see patients with foodborne illnesses should consider that food involved in disease outbreaks may have been contaminated at the point of processing, rather than the point of service.

“Although we think of norovirus contamination occurring at point of service, we suspect that contamination can also occur at point of processing for prepackaged and ready-to-eat foods,” Dr. Barzilay said. Norovirus is highly resilient and can survive on surfaces for extended periods of time, he noted, adding that food handlers who become ill should stay home from work for 24 hours after their symptoms resolve.

DENVER — Depression was nearly twice as common among adults who had been diagnosed with type 2 diabetes, compared with adults who had either normal or impaired fasting plasma glucose levels and those with undiagnosed diabetes, Mirjam J. Knol said in a poster presented at the annual meeting of the American Psychosomatic Society.

The prevalence of depression was 17% in the 3,205 adults with a normal fasting plasma glucose (less than 5.6 mmol/L), 14.6% in the 534 subjects with impaired FPG (5.6–7.0 mmol/L), and 13.3% among 30 undiagnosed subjects who met the criteria for type 2 diabetes (FPG of at least 7.0 mmol/L).

By contrast, the prevalence of depression was 32.7% in the 49 patients who had been diagnosed with type 2 diabetes, wrote Ms. Knol of the University Medical Center, Utrecht (the Netherlands). The study was supported in part by Novo Nordisk.

The data were taken from a larger study, the Utrecht Health Project, and the investigators excluded patients with cardiovascular disease and type 1 diabetes.

Overall, patients who had been diagnosed with type 2 diabetes had a twofold increase in depression, even after adjusting for age, body mass index, smoking, alcohol consumption, physical activity, education level, and the number of comorbid conditions.

The increased risk of depression among diagnosed type 2 diabetes patients suggests that depression in this population is a consequence of the psychosocial burden of the illness, rather than a contributor to it, Ms. Knol wrote.

In a related study aimed at estimating the effects of depression on utilization among patients with newly diagnosed type 2 diabetes, Medicaid claims data were analyzed for more than 4,000 type 2 diabetics with and without depression. Dr. Iftekhar Kalsekar of the College of Pharmacy and Health Sciences, Butler University in Indianapolis, and colleagues found that those with depression had nearly 65% higher overall health care costs than those without depression (Manag. Care Interface 2006;19:39–46).

DENVER — Depression was nearly twice as common among adults who had been diagnosed with type 2 diabetes, compared with adults who had either normal or impaired fasting plasma glucose levels and those with undiagnosed diabetes, Mirjam J. Knol said in a poster presented at the annual meeting of the American Psychosomatic Society.

The prevalence of depression was 17% in the 3,205 adults with a normal fasting plasma glucose (less than 5.6 mmol/L), 14.6% in the 534 subjects with impaired FPG (5.6–7.0 mmol/L), and 13.3% among 30 undiagnosed subjects who met the criteria for type 2 diabetes (FPG of at least 7.0 mmol/L).

By contrast, the prevalence of depression was 32.7% in the 49 patients who had been diagnosed with type 2 diabetes, wrote Ms. Knol of the University Medical Center, Utrecht (the Netherlands). The study was supported in part by Novo Nordisk.

The data were taken from a larger study, the Utrecht Health Project, and the investigators excluded patients with cardiovascular disease and type 1 diabetes.

Overall, patients who had been diagnosed with type 2 diabetes had a twofold increase in depression, even after adjusting for age, body mass index, smoking, alcohol consumption, physical activity, education level, and the number of comorbid conditions.

The increased risk of depression among diagnosed type 2 diabetes patients suggests that depression in this population is a consequence of the psychosocial burden of the illness, rather than a contributor to it, Ms. Knol wrote.

In a related study aimed at estimating the effects of depression on utilization among patients with newly diagnosed type 2 diabetes, Medicaid claims data were analyzed for more than 4,000 type 2 diabetics with and without depression. Dr. Iftekhar Kalsekar of the College of Pharmacy and Health Sciences, Butler University in Indianapolis, and colleagues found that those with depression had nearly 65% higher overall health care costs than those without depression (Manag. Care Interface 2006;19:39–46).

DENVER — Depression was nearly twice as common among adults who had been diagnosed with type 2 diabetes, compared with adults who had either normal or impaired fasting plasma glucose levels and those with undiagnosed diabetes, Mirjam J. Knol said in a poster presented at the annual meeting of the American Psychosomatic Society.

The prevalence of depression was 17% in the 3,205 adults with a normal fasting plasma glucose (less than 5.6 mmol/L), 14.6% in the 534 subjects with impaired FPG (5.6–7.0 mmol/L), and 13.3% among 30 undiagnosed subjects who met the criteria for type 2 diabetes (FPG of at least 7.0 mmol/L).

By contrast, the prevalence of depression was 32.7% in the 49 patients who had been diagnosed with type 2 diabetes, wrote Ms. Knol of the University Medical Center, Utrecht (the Netherlands). The study was supported in part by Novo Nordisk.

The data were taken from a larger study, the Utrecht Health Project, and the investigators excluded patients with cardiovascular disease and type 1 diabetes.

Overall, patients who had been diagnosed with type 2 diabetes had a twofold increase in depression, even after adjusting for age, body mass index, smoking, alcohol consumption, physical activity, education level, and the number of comorbid conditions.

The increased risk of depression among diagnosed type 2 diabetes patients suggests that depression in this population is a consequence of the psychosocial burden of the illness, rather than a contributor to it, Ms. Knol wrote.

In a related study aimed at estimating the effects of depression on utilization among patients with newly diagnosed type 2 diabetes, Medicaid claims data were analyzed for more than 4,000 type 2 diabetics with and without depression. Dr. Iftekhar Kalsekar of the College of Pharmacy and Health Sciences, Butler University in Indianapolis, and colleagues found that those with depression had nearly 65% higher overall health care costs than those without depression (Manag. Care Interface 2006;19:39–46).

DENVER — Depression that occurred in adults after acute myocardial infarction decreased in severity during the first 6 months after the cardiac event, but then stabilized over the next several years, Kenneth E. Freedland, Ph.D., reported in a poster presented at the annual meeting of the American Psychosomatic Society.

Dr. Freedland, a member of the psychiatry department at Washington University, St. Louis, and his colleagues reviewed data on 1,086 adults who were randomized to the usual care arm of the Enhancing Recovery in Coronary Heart Disease (ENRICHD) study, a multicenter trial sponsored by the National Institutes of Health that was designed to evaluate depression interventions in MI patients.

The patients' mean age was 43 years, 44% were female, and 35% were minorities. In addition, 55% were high school graduates, 19% were college graduates, and 26% had less than a high school education. About 60% of the patients had a history of major depression before the MI.

The patients completed a Beck Depression Inventory (BDI) at the start of the study, and again at 6-month intervals for an average follow-up period of 26 months. The average baseline BDI score was 15.3; baseline BDI scores were lowest among older patients, non-Hispanic white patients, and patients without a history of major depression, and highest among women and patients who were taking antidepressants.

Antidepressant use was associated with worse depression in the overall ENRICHD study, so its impact in this analysis must be interpreted with caution, the investigators noted.

Overall, the severity of depression decreased during the first 6 months after the MI, but depression scores then stabilized during the follow-up period, which lasted as long as 4 years for some patients. The average decrease in BDI score was −0.85 during months 0–6, compared with −0.07 during months 6–54.

Female gender, minority status, younger age, and lower levels of education were significantly associated with higher levels of depression immediately after MI, but younger female patients showed the fastest improvements in depressive symptoms over time. Additional analysis is needed to determine patterns among these subgroups, the researchers noted.

DENVER — Depression that occurred in adults after acute myocardial infarction decreased in severity during the first 6 months after the cardiac event, but then stabilized over the next several years, Kenneth E. Freedland, Ph.D., reported in a poster presented at the annual meeting of the American Psychosomatic Society.

Dr. Freedland, a member of the psychiatry department at Washington University, St. Louis, and his colleagues reviewed data on 1,086 adults who were randomized to the usual care arm of the Enhancing Recovery in Coronary Heart Disease (ENRICHD) study, a multicenter trial sponsored by the National Institutes of Health that was designed to evaluate depression interventions in MI patients.

The patients' mean age was 43 years, 44% were female, and 35% were minorities. In addition, 55% were high school graduates, 19% were college graduates, and 26% had less than a high school education. About 60% of the patients had a history of major depression before the MI.

The patients completed a Beck Depression Inventory (BDI) at the start of the study, and again at 6-month intervals for an average follow-up period of 26 months. The average baseline BDI score was 15.3; baseline BDI scores were lowest among older patients, non-Hispanic white patients, and patients without a history of major depression, and highest among women and patients who were taking antidepressants.

Antidepressant use was associated with worse depression in the overall ENRICHD study, so its impact in this analysis must be interpreted with caution, the investigators noted.

Overall, the severity of depression decreased during the first 6 months after the MI, but depression scores then stabilized during the follow-up period, which lasted as long as 4 years for some patients. The average decrease in BDI score was −0.85 during months 0–6, compared with −0.07 during months 6–54.

Female gender, minority status, younger age, and lower levels of education were significantly associated with higher levels of depression immediately after MI, but younger female patients showed the fastest improvements in depressive symptoms over time. Additional analysis is needed to determine patterns among these subgroups, the researchers noted.

DENVER — Depression that occurred in adults after acute myocardial infarction decreased in severity during the first 6 months after the cardiac event, but then stabilized over the next several years, Kenneth E. Freedland, Ph.D., reported in a poster presented at the annual meeting of the American Psychosomatic Society.

Dr. Freedland, a member of the psychiatry department at Washington University, St. Louis, and his colleagues reviewed data on 1,086 adults who were randomized to the usual care arm of the Enhancing Recovery in Coronary Heart Disease (ENRICHD) study, a multicenter trial sponsored by the National Institutes of Health that was designed to evaluate depression interventions in MI patients.

The patients' mean age was 43 years, 44% were female, and 35% were minorities. In addition, 55% were high school graduates, 19% were college graduates, and 26% had less than a high school education. About 60% of the patients had a history of major depression before the MI.

The patients completed a Beck Depression Inventory (BDI) at the start of the study, and again at 6-month intervals for an average follow-up period of 26 months. The average baseline BDI score was 15.3; baseline BDI scores were lowest among older patients, non-Hispanic white patients, and patients without a history of major depression, and highest among women and patients who were taking antidepressants.

Antidepressant use was associated with worse depression in the overall ENRICHD study, so its impact in this analysis must be interpreted with caution, the investigators noted.

Overall, the severity of depression decreased during the first 6 months after the MI, but depression scores then stabilized during the follow-up period, which lasted as long as 4 years for some patients. The average decrease in BDI score was −0.85 during months 0–6, compared with −0.07 during months 6–54.

Female gender, minority status, younger age, and lower levels of education were significantly associated with higher levels of depression immediately after MI, but younger female patients showed the fastest improvements in depressive symptoms over time. Additional analysis is needed to determine patterns among these subgroups, the researchers noted.

DENVER – Phobic anxiety was significantly associated with both ventricular arrhythmia and mortality in coronary artery disease patients during a median 3-year follow-up, said Lana Watkins, Ph.D., at the annual meeting of the American Psychosomatic Society.

The relationship between sudden cardiac death and phobic anxiety in particular has not been well studied, Dr. Watkins noted. She and her colleagues at Duke University Medical Center in Durham, N.C., evaluated 941 adult patients who were being treated for coronary artery disease. A majority of these patients were white males. About a third of the patients did not have high school diplomas, and smoking and obesity were common among patients in the study.

The highest number of arrhythmias occurred among those patients with the highest levels of phobic anxiety based on the Crown-Crisp index, which rates eight types of phobias, including fear of heights, crowds, and closed spaces.

Overall, the highest tertile of phobic anxiety scores had twice as many females as males, and a higher level of phobic anxiety was significantly associated with female sex, minority status, increased body mass index, and younger age.

Despite the finding of an association between phobic anxiety and ventricular arrhythmias, no significant relationship was found between phobic anxiety and sudden cardiac death, Dr. Watkins noted. During a follow-up period, 134 patients died, and 46 of these met the criteria for sudden cardiac death. Sudden cardiac death was defined as death within 72 hours of collapse, in order to account for deaths of patients who lived alone.

However, mortality was highest among patients with high levels of phobic anxiety, Dr. Watkins said. The predictability of phobic anxiety for both mortality and an increased risk of ventricular arrhythmias was maintained in a regression analysis after other predictors of mortality including age, gender, education level, and comorbidities were adjusted for.

DENVER – Phobic anxiety was significantly associated with both ventricular arrhythmia and mortality in coronary artery disease patients during a median 3-year follow-up, said Lana Watkins, Ph.D., at the annual meeting of the American Psychosomatic Society.

The relationship between sudden cardiac death and phobic anxiety in particular has not been well studied, Dr. Watkins noted. She and her colleagues at Duke University Medical Center in Durham, N.C., evaluated 941 adult patients who were being treated for coronary artery disease. A majority of these patients were white males. About a third of the patients did not have high school diplomas, and smoking and obesity were common among patients in the study.

The highest number of arrhythmias occurred among those patients with the highest levels of phobic anxiety based on the Crown-Crisp index, which rates eight types of phobias, including fear of heights, crowds, and closed spaces.

Overall, the highest tertile of phobic anxiety scores had twice as many females as males, and a higher level of phobic anxiety was significantly associated with female sex, minority status, increased body mass index, and younger age.

Despite the finding of an association between phobic anxiety and ventricular arrhythmias, no significant relationship was found between phobic anxiety and sudden cardiac death, Dr. Watkins noted. During a follow-up period, 134 patients died, and 46 of these met the criteria for sudden cardiac death. Sudden cardiac death was defined as death within 72 hours of collapse, in order to account for deaths of patients who lived alone.

However, mortality was highest among patients with high levels of phobic anxiety, Dr. Watkins said. The predictability of phobic anxiety for both mortality and an increased risk of ventricular arrhythmias was maintained in a regression analysis after other predictors of mortality including age, gender, education level, and comorbidities were adjusted for.

DENVER – Phobic anxiety was significantly associated with both ventricular arrhythmia and mortality in coronary artery disease patients during a median 3-year follow-up, said Lana Watkins, Ph.D., at the annual meeting of the American Psychosomatic Society.

The relationship between sudden cardiac death and phobic anxiety in particular has not been well studied, Dr. Watkins noted. She and her colleagues at Duke University Medical Center in Durham, N.C., evaluated 941 adult patients who were being treated for coronary artery disease. A majority of these patients were white males. About a third of the patients did not have high school diplomas, and smoking and obesity were common among patients in the study.

The highest number of arrhythmias occurred among those patients with the highest levels of phobic anxiety based on the Crown-Crisp index, which rates eight types of phobias, including fear of heights, crowds, and closed spaces.

Overall, the highest tertile of phobic anxiety scores had twice as many females as males, and a higher level of phobic anxiety was significantly associated with female sex, minority status, increased body mass index, and younger age.

Despite the finding of an association between phobic anxiety and ventricular arrhythmias, no significant relationship was found between phobic anxiety and sudden cardiac death, Dr. Watkins noted. During a follow-up period, 134 patients died, and 46 of these met the criteria for sudden cardiac death. Sudden cardiac death was defined as death within 72 hours of collapse, in order to account for deaths of patients who lived alone.

However, mortality was highest among patients with high levels of phobic anxiety, Dr. Watkins said. The predictability of phobic anxiety for both mortality and an increased risk of ventricular arrhythmias was maintained in a regression analysis after other predictors of mortality including age, gender, education level, and comorbidities were adjusted for.

DENVER – End-stage liver disease was associated with significant deficits in memory, abstract thought, sustained attention, and executive function in a study of 104 adult patients, Tina Meyer, Ph.D., reported in a poster presented at the annual meeting of the American Psychosomatic Society.

“We want to enlighten the surgeons and primary care doctors that cognitive decline can indicate serious liver problems,” Dr. Meyer said in an interview. She and her colleagues in the Transplant Institute at the Henry Ford Health System in Detroit enrolled liver disease patients who met medical and psychosocial criteria for a transplant. About half (51%) were male, 74% were white, and the average age was 54 years. The patients' mean score on the model for end-stage liver disease (MELD) was 11.3.

The participants completed a cognitive assessment including the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), which estimates brain function in five different domains: immediate memory, delayed memory, visuospatial abilities, language, and attention.

Overall, scores on the RBANS were below average on the subtests of immediate memory, visuospatial abilities, and attention. After the investigators controlled for education levels, higher MELD scores were significantly associated with lower scores on the immediate memory and delayed memory subtests of RBANS, as well as with lower scores on the Mini-Mental State Exam, the Shipley Institute of Living Scale, and the Trail-Making Test, parts A and B.

DENVER – End-stage liver disease was associated with significant deficits in memory, abstract thought, sustained attention, and executive function in a study of 104 adult patients, Tina Meyer, Ph.D., reported in a poster presented at the annual meeting of the American Psychosomatic Society.

“We want to enlighten the surgeons and primary care doctors that cognitive decline can indicate serious liver problems,” Dr. Meyer said in an interview. She and her colleagues in the Transplant Institute at the Henry Ford Health System in Detroit enrolled liver disease patients who met medical and psychosocial criteria for a transplant. About half (51%) were male, 74% were white, and the average age was 54 years. The patients' mean score on the model for end-stage liver disease (MELD) was 11.3.

The participants completed a cognitive assessment including the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), which estimates brain function in five different domains: immediate memory, delayed memory, visuospatial abilities, language, and attention.

Overall, scores on the RBANS were below average on the subtests of immediate memory, visuospatial abilities, and attention. After the investigators controlled for education levels, higher MELD scores were significantly associated with lower scores on the immediate memory and delayed memory subtests of RBANS, as well as with lower scores on the Mini-Mental State Exam, the Shipley Institute of Living Scale, and the Trail-Making Test, parts A and B.

DENVER – End-stage liver disease was associated with significant deficits in memory, abstract thought, sustained attention, and executive function in a study of 104 adult patients, Tina Meyer, Ph.D., reported in a poster presented at the annual meeting of the American Psychosomatic Society.

“We want to enlighten the surgeons and primary care doctors that cognitive decline can indicate serious liver problems,” Dr. Meyer said in an interview. She and her colleagues in the Transplant Institute at the Henry Ford Health System in Detroit enrolled liver disease patients who met medical and psychosocial criteria for a transplant. About half (51%) were male, 74% were white, and the average age was 54 years. The patients' mean score on the model for end-stage liver disease (MELD) was 11.3.

The participants completed a cognitive assessment including the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), which estimates brain function in five different domains: immediate memory, delayed memory, visuospatial abilities, language, and attention.

Overall, scores on the RBANS were below average on the subtests of immediate memory, visuospatial abilities, and attention. After the investigators controlled for education levels, higher MELD scores were significantly associated with lower scores on the immediate memory and delayed memory subtests of RBANS, as well as with lower scores on the Mini-Mental State Exam, the Shipley Institute of Living Scale, and the Trail-Making Test, parts A and B.

More than 1,000 cases of mumps in nine states have been confirmed in the nation's largest mumps outbreak in decades, announced Dr. Julie Gerberding, director of the Centers for Disease Control and Prevention, Atlanta.

The outbreak began in Iowa in December 2005 among college students, whose close living conditions make them susceptible to the virus, Dr. Gerberding said in a press briefing. By comparison, a yearly average of 265 mumps cases have been reported for the entire country since 2001, while Iowa previously averaged just 5 cases per year since 1996, the CDC reported (MMWR [Dispatch] 2006;55:1–3).

“As clinicians become more aware of what we are looking for, we expect more cases will be diagnosed,” Dr. Gerberding said. “A lot of clinicians have never seen a case of mumps. Not everyone presents with swollen glands.”

Most cases occurred in people aged 18–25 years, many of whom had received either one or two doses of the mumps vaccine. Cases are under investigation in Illinois, Indiana, Kansas, Michigan, Minnesota, Missouri, Nebraska, and Wisconsin. Dr. Gerberding declined to name additional states in which suspected but unconfirmed cases are under investigation.

In addition, two individuals have been identified in Iowa who were potentially infectious during nine different commercial flights between March 26 and April 2, to or from cities outside the Midwest, including Tucson, Ariz.; Dallas; and Washington, the CDC said in an official health advisory issued on April 14.

Mumps, an acute viral upper respiratory infection, may present initially with nonspecific symptoms such as myalgia, anorexia, malaise, headache, and fever, and progress to acute onset of unilateral or bilateral tenderness and swelling of parotid or other salivary glands. About 30%–70% of unvaccinated people develop typical acute parotitis, but up to 20% of infections are asymptomatic; nearly 50% are associated with nonspecific symptoms or symptoms that are primarily respiratory, with or without parotitis. Severe complications can include deafness, orchitis, oophoritis, mastitis, meningitis/encephalitis, and spontaneous abortion.

Most people with mumps are ill for about a week, and they can be contagious from 3 days before symptoms appear until about 9 days after the appearance of symptoms, according to the CDC.

“It's very important for health care workers to have a second dose of the MMR vaccine,” Dr. Gerberding emphasized.

Health care providers in affected areas are advised to offer the MMR vaccine to individuals without evidence of immunity, including all unvaccinated persons born after 1957. In addition, a second dose is recommended for school-age children, college students, and other high-risk groups. Most children have received both doses, but vaccine coverage rates vary with location and population, Dr. Gerberding said.

The supply of MMR vaccine is adequate to cope with the outbreak, she said. The CDC will assist states with vaccine supplies as needed, and Merck has donated 25,000 doses to the CDC's stockpile.

The problem, Dr. Gerberding said, is a lack of complete coverage with a vaccine that is not 100% effective. About 10% of people who receive both doses simply fail to respond and remain susceptible to mumps.

Individuals suspected to have mumps should be tested and any positive cases reported immediately to local public health officials. Such individuals should be isolated for 9 days after symptom onset, the CDC advised.

Physicians should familiarize themselves with the clinical presentations of mumps, infectious disease specialist Dr. Mary Anne Jackson told this newspaper. Some patients complain of pain at the corner of the jaw, or of an earache that can be confused with otitis. Ovarian inflammation, which may occur in up to 5% of infected postpubertal females, may be confused with appendicitis.

Symptomatic meningitis, which occurs in up to 15% of cases, is associated with a lymphocytic pleocytosis (inflammatory cells in the spinal fluid) that is typical of viral meningitis, but with a low CSF glucose level. Typical summertime enterovirus meningitis is usually associated with normal or low-normal CSF glucose levels, typically around 40%–50% of peripheral glucose. With mumps meningitis, those levels might be 10%–25%. It's important to rule out bacterial meningitis, which a low CSF glucose might suggest, said Dr. Jackson, chief of infectious disease at Children's Mercy Hospital, Kansas City, Mo.

When mumps is suspected, options include culturing the nasopharynx, throat, or urine or testing for serum IgM antibodies. Standard shell vial culture could miss mumps, so ensure that your laboratory's culture will identify mumps, she advised.

At the time of the press briefing, no deaths related to the mumps outbreak had been reported, Dr. Gerberding said. “We hope the containment steps that are being taken at the state levels will help to slow things down,” she said.

Further information from the CDC is available at www.cdc.gov/nip/diseases/mumps/mumps-outbreak.htm

More than 1,000 cases of mumps in nine states have been confirmed in the nation's largest mumps outbreak in decades, announced Dr. Julie Gerberding, director of the Centers for Disease Control and Prevention, Atlanta.

The outbreak began in Iowa in December 2005 among college students, whose close living conditions make them susceptible to the virus, Dr. Gerberding said in a press briefing. By comparison, a yearly average of 265 mumps cases have been reported for the entire country since 2001, while Iowa previously averaged just 5 cases per year since 1996, the CDC reported (MMWR [Dispatch] 2006;55:1–3).

“As clinicians become more aware of what we are looking for, we expect more cases will be diagnosed,” Dr. Gerberding said. “A lot of clinicians have never seen a case of mumps. Not everyone presents with swollen glands.”

Most cases occurred in people aged 18–25 years, many of whom had received either one or two doses of the mumps vaccine. Cases are under investigation in Illinois, Indiana, Kansas, Michigan, Minnesota, Missouri, Nebraska, and Wisconsin. Dr. Gerberding declined to name additional states in which suspected but unconfirmed cases are under investigation.

In addition, two individuals have been identified in Iowa who were potentially infectious during nine different commercial flights between March 26 and April 2, to or from cities outside the Midwest, including Tucson, Ariz.; Dallas; and Washington, the CDC said in an official health advisory issued on April 14.

Mumps, an acute viral upper respiratory infection, may present initially with nonspecific symptoms such as myalgia, anorexia, malaise, headache, and fever, and progress to acute onset of unilateral or bilateral tenderness and swelling of parotid or other salivary glands. About 30%–70% of unvaccinated people develop typical acute parotitis, but up to 20% of infections are asymptomatic; nearly 50% are associated with nonspecific symptoms or symptoms that are primarily respiratory, with or without parotitis. Severe complications can include deafness, orchitis, oophoritis, mastitis, meningitis/encephalitis, and spontaneous abortion.

Most people with mumps are ill for about a week, and they can be contagious from 3 days before symptoms appear until about 9 days after the appearance of symptoms, according to the CDC.

“It's very important for health care workers to have a second dose of the MMR vaccine,” Dr. Gerberding emphasized.

Health care providers in affected areas are advised to offer the MMR vaccine to individuals without evidence of immunity, including all unvaccinated persons born after 1957. In addition, a second dose is recommended for school-age children, college students, and other high-risk groups. Most children have received both doses, but vaccine coverage rates vary with location and population, Dr. Gerberding said.

The supply of MMR vaccine is adequate to cope with the outbreak, she said. The CDC will assist states with vaccine supplies as needed, and Merck has donated 25,000 doses to the CDC's stockpile.

The problem, Dr. Gerberding said, is a lack of complete coverage with a vaccine that is not 100% effective. About 10% of people who receive both doses simply fail to respond and remain susceptible to mumps.

Individuals suspected to have mumps should be tested and any positive cases reported immediately to local public health officials. Such individuals should be isolated for 9 days after symptom onset, the CDC advised.

Physicians should familiarize themselves with the clinical presentations of mumps, infectious disease specialist Dr. Mary Anne Jackson told this newspaper. Some patients complain of pain at the corner of the jaw, or of an earache that can be confused with otitis. Ovarian inflammation, which may occur in up to 5% of infected postpubertal females, may be confused with appendicitis.

Symptomatic meningitis, which occurs in up to 15% of cases, is associated with a lymphocytic pleocytosis (inflammatory cells in the spinal fluid) that is typical of viral meningitis, but with a low CSF glucose level. Typical summertime enterovirus meningitis is usually associated with normal or low-normal CSF glucose levels, typically around 40%–50% of peripheral glucose. With mumps meningitis, those levels might be 10%–25%. It's important to rule out bacterial meningitis, which a low CSF glucose might suggest, said Dr. Jackson, chief of infectious disease at Children's Mercy Hospital, Kansas City, Mo.

When mumps is suspected, options include culturing the nasopharynx, throat, or urine or testing for serum IgM antibodies. Standard shell vial culture could miss mumps, so ensure that your laboratory's culture will identify mumps, she advised.

At the time of the press briefing, no deaths related to the mumps outbreak had been reported, Dr. Gerberding said. “We hope the containment steps that are being taken at the state levels will help to slow things down,” she said.

Further information from the CDC is available at www.cdc.gov/nip/diseases/mumps/mumps-outbreak.htm

More than 1,000 cases of mumps in nine states have been confirmed in the nation's largest mumps outbreak in decades, announced Dr. Julie Gerberding, director of the Centers for Disease Control and Prevention, Atlanta.

The outbreak began in Iowa in December 2005 among college students, whose close living conditions make them susceptible to the virus, Dr. Gerberding said in a press briefing. By comparison, a yearly average of 265 mumps cases have been reported for the entire country since 2001, while Iowa previously averaged just 5 cases per year since 1996, the CDC reported (MMWR [Dispatch] 2006;55:1–3).

“As clinicians become more aware of what we are looking for, we expect more cases will be diagnosed,” Dr. Gerberding said. “A lot of clinicians have never seen a case of mumps. Not everyone presents with swollen glands.”

Most cases occurred in people aged 18–25 years, many of whom had received either one or two doses of the mumps vaccine. Cases are under investigation in Illinois, Indiana, Kansas, Michigan, Minnesota, Missouri, Nebraska, and Wisconsin. Dr. Gerberding declined to name additional states in which suspected but unconfirmed cases are under investigation.

In addition, two individuals have been identified in Iowa who were potentially infectious during nine different commercial flights between March 26 and April 2, to or from cities outside the Midwest, including Tucson, Ariz.; Dallas; and Washington, the CDC said in an official health advisory issued on April 14.

Mumps, an acute viral upper respiratory infection, may present initially with nonspecific symptoms such as myalgia, anorexia, malaise, headache, and fever, and progress to acute onset of unilateral or bilateral tenderness and swelling of parotid or other salivary glands. About 30%–70% of unvaccinated people develop typical acute parotitis, but up to 20% of infections are asymptomatic; nearly 50% are associated with nonspecific symptoms or symptoms that are primarily respiratory, with or without parotitis. Severe complications can include deafness, orchitis, oophoritis, mastitis, meningitis/encephalitis, and spontaneous abortion.

Most people with mumps are ill for about a week, and they can be contagious from 3 days before symptoms appear until about 9 days after the appearance of symptoms, according to the CDC.

“It's very important for health care workers to have a second dose of the MMR vaccine,” Dr. Gerberding emphasized.

Health care providers in affected areas are advised to offer the MMR vaccine to individuals without evidence of immunity, including all unvaccinated persons born after 1957. In addition, a second dose is recommended for school-age children, college students, and other high-risk groups. Most children have received both doses, but vaccine coverage rates vary with location and population, Dr. Gerberding said.

The supply of MMR vaccine is adequate to cope with the outbreak, she said. The CDC will assist states with vaccine supplies as needed, and Merck has donated 25,000 doses to the CDC's stockpile.

The problem, Dr. Gerberding said, is a lack of complete coverage with a vaccine that is not 100% effective. About 10% of people who receive both doses simply fail to respond and remain susceptible to mumps.

Individuals suspected to have mumps should be tested and any positive cases reported immediately to local public health officials. Such individuals should be isolated for 9 days after symptom onset, the CDC advised.

Physicians should familiarize themselves with the clinical presentations of mumps, infectious disease specialist Dr. Mary Anne Jackson told this newspaper. Some patients complain of pain at the corner of the jaw, or of an earache that can be confused with otitis. Ovarian inflammation, which may occur in up to 5% of infected postpubertal females, may be confused with appendicitis.

Symptomatic meningitis, which occurs in up to 15% of cases, is associated with a lymphocytic pleocytosis (inflammatory cells in the spinal fluid) that is typical of viral meningitis, but with a low CSF glucose level. Typical summertime enterovirus meningitis is usually associated with normal or low-normal CSF glucose levels, typically around 40%–50% of peripheral glucose. With mumps meningitis, those levels might be 10%–25%. It's important to rule out bacterial meningitis, which a low CSF glucose might suggest, said Dr. Jackson, chief of infectious disease at Children's Mercy Hospital, Kansas City, Mo.

When mumps is suspected, options include culturing the nasopharynx, throat, or urine or testing for serum IgM antibodies. Standard shell vial culture could miss mumps, so ensure that your laboratory's culture will identify mumps, she advised.

At the time of the press briefing, no deaths related to the mumps outbreak had been reported, Dr. Gerberding said. “We hope the containment steps that are being taken at the state levels will help to slow things down,” she said.

Further information from the CDC is available at www.cdc.gov/nip/diseases/mumps/mumps-outbreak.htm

ATLANTA — As summer approaches, it may be wise to be wary of berries. Five norovirus outbreaks affecting several hundred people in Denmark in 2005 were traced to a single batch of contaminated frozen raspberries, Dr. Gerhard Falkenhorst reported at the International Conference on Emerging Infectious Diseases.

The first cases of illness in each outbreak appeared within 24 hours after the patients ate a raspberry dessert, and norovirus was detected in stool samples from all but one outbreak, said Dr. Falkenhorst, of the Statens Serum Institut, Copenhagen.

The outbreaks occurred between May and September 2005, and all of them involved mass catering settings—one hospital, one “meals-on-wheels” service, one restaurant, and two nursing homes. All of the outbreaks involved desserts made with frozen raspberries.

The first outbreak occurred in a hospital, and both patients and staff members reported acute gastroenteritis. Ultimately, nearly 450 cases occurred in this outbreak. Several cases occurred simultaneously, which suggested a foodborne cause, and norovirus was discovered in food tracings that implicated a dessert made with raspberries that were part of a single, large shipment from Poland.

Although the supplier began a voluntary recall of the shipment, the affected raspberries had already been sent to other clients and were linked to several other outbreaks.

The second outbreak affected about 70 residents and staff members at a nursing home the day after a raspberry dessert had been served, and the third outbreak struck several hundred clients of a “meals-on-wheels” service, which reported diarrhea and vomiting among its clients within 2 days after they had received raspberry desserts. The attack rate was especially high among patients aged 85 years and older, Dr. Falkenhorst noted.

A case-control study confirmed that all the desserts associated with the outbreaks were prepared with crushed, frozen raspberries from the same batch imported from Poland. The same norovirus genogroup (II.7) was identified in 24 of 54 stool samples from one outbreak and 9 of 11 stool samples from the second outbreak. Also, norovirus genogroup II.4 was found in 15 of 15 samples from a third outbreak and genogroup II.b was found in 4 of 8 samples from another outbreak.

This series is the first time several norovirus strains were found in stool samples involving the same raspberry vehicle, Dr. Falkenhorst noted.

ATLANTA — As summer approaches, it may be wise to be wary of berries. Five norovirus outbreaks affecting several hundred people in Denmark in 2005 were traced to a single batch of contaminated frozen raspberries, Dr. Gerhard Falkenhorst reported at the International Conference on Emerging Infectious Diseases.

The first cases of illness in each outbreak appeared within 24 hours after the patients ate a raspberry dessert, and norovirus was detected in stool samples from all but one outbreak, said Dr. Falkenhorst, of the Statens Serum Institut, Copenhagen.

The outbreaks occurred between May and September 2005, and all of them involved mass catering settings—one hospital, one “meals-on-wheels” service, one restaurant, and two nursing homes. All of the outbreaks involved desserts made with frozen raspberries.

The first outbreak occurred in a hospital, and both patients and staff members reported acute gastroenteritis. Ultimately, nearly 450 cases occurred in this outbreak. Several cases occurred simultaneously, which suggested a foodborne cause, and norovirus was discovered in food tracings that implicated a dessert made with raspberries that were part of a single, large shipment from Poland.

Although the supplier began a voluntary recall of the shipment, the affected raspberries had already been sent to other clients and were linked to several other outbreaks.

The second outbreak affected about 70 residents and staff members at a nursing home the day after a raspberry dessert had been served, and the third outbreak struck several hundred clients of a “meals-on-wheels” service, which reported diarrhea and vomiting among its clients within 2 days after they had received raspberry desserts. The attack rate was especially high among patients aged 85 years and older, Dr. Falkenhorst noted.

A case-control study confirmed that all the desserts associated with the outbreaks were prepared with crushed, frozen raspberries from the same batch imported from Poland. The same norovirus genogroup (II.7) was identified in 24 of 54 stool samples from one outbreak and 9 of 11 stool samples from the second outbreak. Also, norovirus genogroup II.4 was found in 15 of 15 samples from a third outbreak and genogroup II.b was found in 4 of 8 samples from another outbreak.

This series is the first time several norovirus strains were found in stool samples involving the same raspberry vehicle, Dr. Falkenhorst noted.

ATLANTA — As summer approaches, it may be wise to be wary of berries. Five norovirus outbreaks affecting several hundred people in Denmark in 2005 were traced to a single batch of contaminated frozen raspberries, Dr. Gerhard Falkenhorst reported at the International Conference on Emerging Infectious Diseases.

The first cases of illness in each outbreak appeared within 24 hours after the patients ate a raspberry dessert, and norovirus was detected in stool samples from all but one outbreak, said Dr. Falkenhorst, of the Statens Serum Institut, Copenhagen.

The outbreaks occurred between May and September 2005, and all of them involved mass catering settings—one hospital, one “meals-on-wheels” service, one restaurant, and two nursing homes. All of the outbreaks involved desserts made with frozen raspberries.

The first outbreak occurred in a hospital, and both patients and staff members reported acute gastroenteritis. Ultimately, nearly 450 cases occurred in this outbreak. Several cases occurred simultaneously, which suggested a foodborne cause, and norovirus was discovered in food tracings that implicated a dessert made with raspberries that were part of a single, large shipment from Poland.

Although the supplier began a voluntary recall of the shipment, the affected raspberries had already been sent to other clients and were linked to several other outbreaks.

The second outbreak affected about 70 residents and staff members at a nursing home the day after a raspberry dessert had been served, and the third outbreak struck several hundred clients of a “meals-on-wheels” service, which reported diarrhea and vomiting among its clients within 2 days after they had received raspberry desserts. The attack rate was especially high among patients aged 85 years and older, Dr. Falkenhorst noted.

A case-control study confirmed that all the desserts associated with the outbreaks were prepared with crushed, frozen raspberries from the same batch imported from Poland. The same norovirus genogroup (II.7) was identified in 24 of 54 stool samples from one outbreak and 9 of 11 stool samples from the second outbreak. Also, norovirus genogroup II.4 was found in 15 of 15 samples from a third outbreak and genogroup II.b was found in 4 of 8 samples from another outbreak.

This series is the first time several norovirus strains were found in stool samples involving the same raspberry vehicle, Dr. Falkenhorst noted.